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May 3, 2022 Circulation. 2022;145:e895–e1032. DOI: 10.1161/CIR.0000000000001063 e946 CLINICAL STATEMENTS AND GUIDELINES disease and HF.1,4,10–14 Long-term follow-up shows a reduction in all-cause, cardiovascular, and HF hospitalizations and in all-cause and cardiovascular mortality in patients with LV dysfunction who receive CABG and GDMT compared with GDMT alone.2,7 The long-term survival benefit is greater in those with more advanced ischemic cardiomyopathy (lower EF or 3-vessel disease) and diminishes with increasing age.5,7 CABG also improves QOL compared with GDMT alone.3 An RCT of CABG combined with surgical ventricular remodeling compared with CABG alone did not show a reduction in death or hospitalization, or improvement in symptoms with surgical ventricular remodeling.15 Surgical ventricular remodeling performed at the time of CABG may be useful in patients with intractable HF, large thrombus, or persistent arrhythmias resulting from well-defined aneurysm or scar, if other therapies are ineffective or contraindicated.15,16 7.5 Valvular Heart Disease Recommendations for Valvular Heart Disease Referenced studies that support the recommendations are summarized in the Online Data Supplements. COR LOE Recommendations 1 B-R 1. In patients with HF, VHD should be managed in a multidisciplinary manner in accordance with clinical practice guidelines for VHD to prevent worsening of HF and adverse clinical outcomes.1–11 1 C-LD 2. In patients with chronic severe secondary MR and HFrEF, optimization of GDMT is recommended before any intervention for secondary MR related to LV dysfunction.3–5,12–14 Synopsis GDMT applies to all patients with HFrEF, irrespective of the presence of VHD. Significant valve disease warrants evaluation by a multidisciplinary team with expertise in VHD, and management should proceed in accordance with the VHD guidelines.15 Mitral Regurgitation Optimization of GDMT can improve secondary MR associated with LV dysfunction and obviate the need for intervention.14,16,17 Therefore, optimizing GDMT and reassessing MR before MV interventions are important. Patients with persistent severe secondary MR despite GDMT may benefit from either surgical or transcatheter repair, depending on clinical scenario. Thus, patientcentric conversation with a multidisciplinary cardiovascular team that includes a cardiologist with expertise in HF is essential when considering MV intervention.15 Two RCTs of transcatheter mitral valve edge-to-edge repair (TEER) in patients with HFrEF and severe secondary MR have been performed. The COAPT trial showed significant reduction in HF and all-cause mor- tality in patients treated with TEER and GDMT compared with GDMT alone, while MITRA-FR (Multicentre Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients With Severe Secondary Mitral Regurgitation) showed no benefit of TEER over GDMT in reducing death or hospitalization.6 Specifically, transcatheter edge-to-edge MV repair has been shown to be beneficial in patients with persistent symptoms despite GDMT, appropriate anatomy on transesophageal echocardiography and with LVEF between 20% and 50%, LVESD ≤70 mm, and pulmonary artery systolic pressure ≤70 mm Hg6 (Figure 10). Optimal management of secondary MR may depend on the degree of MR relative to LV remodeling.4,5,14,18–22 Disproportionate MR (MR out of proportion to LV remodeling) may respond better to procedural interventions that reduce MR, such as CRT, TEER, and MV surgery. Proportionate MR may respond to measures that reverse LV remodeling and reduce LV volumes, such as GDMT and CRT. Aortic Stenosis In patients with symptomatic aortic stenosis, transcatheter and surgical aortic valve repair can improve survival, symptoms, and LV function.15 However, the choice of transcatheter aortic valve implantation versus surgical aortic valve replacement is based on shared decisionmaking, indications, and assessment of the risk-benefit profile.23,24 The benefit of GDMT in nonsevere aortic stenosis and HFrEF is being evaluated in the TAVR UNLOAD (Transcatheter Aortic Valve Replacement to Unload the Left Ventricle in Patients With Advanced Heart Failure) trial.25 GDMT is usually continued in conjunction with clinical surveillance and imaging in patients with nonsevere aortic stenosis and reduced EF. Tricuspid Regurgitation The severity of secondary tricuspid regurgitation may be dynamic, depending on RV function and pulmonary hypertension, and management entails focusing on underlying causes, such as pulmonary hypertension, RV failure, and HFrEF. Referral to the multidisciplinary team for consideration of intervention might be helpful in patients with refractory tricuspid regurgitation. Recommendation-Specific Supportive Text 1. VHD is a significant cause of HF. In patients with HF, management of VHD should be performed by a multidisciplinary team with expertise in HF and VHD, in accordance with the VHD guidelines.15 Cardiologists with expertise in the management of HF are integral to the multidisciplinary team and to guiding the optimization of GDMT in patients with HF and coexisting valve disease. Severe aortic stenosis, aortic regurgitation, MR, and tricuspid regurgitation are associated with adverse outcomes and require timely assessment, optimization of medical Downloaded from http://ahajournals.org by on October 7, 2026